DATE FOCUS D A R

DECEMBER 8, 2019 Initial assessment D – Received alert oriented and cooperative with
10:45 AM weight of 50 kilograms and a BMI of 17.8

D - Received alert oriented and cooperative with

11:00 am Imbalanced weight of 50 kilograms and a BMI of 17.8. Diminished
nutrition appetite and weight loss, easy fatigability,
decreased subcutaneous fat/muscle mass
A – note exact weight and Body mass index (BMI) in
the morning before meals, do not estimate because
will be used as basis for caloric and nutrient
requirements. Refer to a dietitian for complete
nutrition assessment and diet plan. Give good oral
hygiene to reduce bacteria in the mouth. Reduce
distraction during meal time and drink 8-10 glasses
of water a day to stay hydrated by giving fluids 1
hour before or after meals.
R – Demonstrated increased appetite by eating
frequent small meals throughout the day containing
vitamins and mineral, protein and calorie rich foods
and 8-10 glasses of water. Increased weight

DECEMBER 12, 2019 DISCHARGE D –Discussed Chemotherapy and Radiation Therapy to

2:00 pm the patient. Patient is undecisive. May go home as
PLANNING ordered by the physician, with the following take home
medications: Augmentin 500 mg po every 12 hrs for 2
days and Ibuprofen 500 mg tab every 8 hrs PRN for
pain
A – Provide education about medications taken
home; Augmentin 500 mg po every 12 hrs for 2 days,
it so be taken on an empty stomach or with a meal
to reduce stomach upset and help the body absorb
the drug better. Ibuprofen 500 mg tab every 8 hrs
PRN for pain, also to be taken with meals. Instruct
family or significant other to provide a keep
environmental pollutant to a minimum, tell neighbors
and other family members to keep a low toned voice to
allow rest. Discussed patient of the benefits of
chemotherapy and radiation therapy. Discuss the
severity of the disease to the patient and the family to
help with making health decisions, managing the effects
of cancer. By following the diet plan, importance of
hygiene and proper hand washing will prevent
contamination to decrease risk of infection. Advice
patient of follow up check-up in one week at the OPD
clinic or oncology unit. Instruct that the diet should
consist of high vitamins and minerals, protein and
calories to help regain and maintain the desired wight of
52-70 kilograms. Have the family monitor fluid intake of
8-10 glasses a day.
R - Verbalize understanding of the importance in
adherence to taking medications, following diet plan,
and exercise. Be able to continue his daily activities with
minimal assistance and active cooperation of plan of
care such as maintaining good oral hygiene, proper hand
washing and a healthy weight.